Citation Nr: 0120198
Decision Date: 08/07/01 Archive Date: 08/14/01
DOCKET NO. 99-04 811 ) DATE
)
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On appeal from the
Department of Veterans Affairs Regional Office in Waco, Texas
THE ISSUES
1. Entitlement to an evaluation in excess of 40 percent for
a lumbosacral strain.
2. Entitlement to an evaluation in excess of 20 percent for
a duodenal ulcer.
3. Entitlement to an evaluation in excess of 10 percent for
a left knee disability.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESSES AT HEARING ON APPEAL
Veteran and ADL
ATTORNEY FOR THE BOARD
J. Johnston, Counsel
INTRODUCTION
The veteran had active military service from December 1943 to
January 1946.
This matter comes before the Board of Veterans' Appeals
(Board) on appeal from a February 1998 rating decision issued
by the Department of Veterans Affairs (VA) Regional Office
(RO) in Waco, Texas, which denied the veteran's claims for
ratings in excess of 20 percent for a lumbosacral strain, in
excess of 10 percent for a left knee disability, and in
excess of 10 percent for a duodenal ulcer. However,
subsequent to VA examinations, the RO issued a rating action
in August 1999 granting the veteran increased evaluations for
lumbosacral strain to 40 percent and for duodenal ulcer to
20 percent, effective from the date of the receipt of his
claims for increase in August 1997. That rating action
confirmed and continued the long-standing 10 percent
evaluation for left knee impairment. The veteran and a
friend testified at a personal hearing at the RO in March
2000.
Although higher ratings of 40 and 20 percent have been
assigned for the veteran's low back disability and peptic
ulcer disease, respectively, as they are not the maximum
ratings available for these disabilities, both claims remain
in appellate status. AB v. Brown, 6 Vet. App. 35 (1993).
FINDINGS OF FACT
1. All evidence necessary for a fair and equitable
disposition of the appeal has been requested or obtained, the
veteran and his representative have been advised of the
evidence necessary to substantiate the claims at issue in
this appeal, VA examinations have been provided, and there
remains no evidence identified by the veteran which is
uncollected for review.
2. The veteran's service-connected low back disability is
manifested by degenerative joint disease and severe
limitation of motion with pain on motion; it is not
productive of unfavorable ankylosis of the lumbar spine.
3. The veteran's service-connected duodenal ulcer is
manifested by continuous moderate manifestations but there is
no evidence of recurrent incapacitating episodes four or more
times per year.
4. The veteran's left knee impairment is manifested by
arthritis with slight limitation of motion and pain on use,
and slight instability.
CONCLUSIONS OF LAW
1. The criteria for an evaluation in excess of 40 percent
for lumbosacral strain have not been met. 38 U.S.C.A. § 1155
(West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10,
4.71a, Diagnostic Codes 5289, 5292, 5295 (2000).
2. The criteria for an evaluation in excess of 20 percent
for duodenal ulcer have not been met. 38 U.S.C.A. § 1155
(West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.114,
Diagnostic Code 7305 (2000).
3. The criteria for an evaluation of 20 percent for a left
knee disability have been met. 38 U.S.C.A. § 1155 (West
1991); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10,
4.40, 4.45, 4.59, Diagnostic Codes 5256-5262 (2000).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
Law and Regulation: The 1945 Schedule for Rating
Disabilities (Schedule) will be used for evaluating the
degree of disabilities in claims for disability compensation.
The provisions of the Rating Schedule represent the average
impairment in earning capacity in civil occupations resulting
from those disabilities, as far as this can practicably be
determined. Separate diagnostic codes identify the various
disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1.
Where there is a question as to which of two evaluations
shall be applied, the higher evaluation will be assigned if
the disability more nearly approximates the criteria required
for that rating, otherwise the lower rating will be assigned.
38 C.F.R. § 4.7. Any reasonable doubt regarding degree of
disability will be resolved in favor of the claimant.
38 C.F.R. § 4.3. The basis of disability evaluations is the
ability of the body as a whole or of a system or organ of the
body to function under the ordinary conditions of daily life
including employment. 38 C.F.R. § 4.10.
Where entitlement to compensation has already been
established and an increase in the disability rating is at
issue, the present level of disability is of primary concern.
Although rating specialists are directed to review the
recorded history of disability to make a more accurate
evaluation, regulations do not give past medical reports
precedence over current findings. 38 C.F.R. § 4.2;
Francisco v. Brown, 7 Vet. App. 55 (1994).
The words "slight," "moderate," and "severe" are not defined
in the Schedule. Rather than applying a mechanical formula,
the Board must evaluate all of the evidence to the end that
its decisions are "equitable and just." 38 C.F.R. § 4.6. It
should be noted that the use of terminology such as
"moderate" by VA examiners and others, although an element of
evidence to be considered by the Board, is not necessarily
dispositive of an issue; all evidence must be evaluated in
arriving at a decision regarding an increased rating.
38 C.F.R. §§ 4.2, 4.6.
Disability of the musculoskeletal system is primarily the
inability to perform the normal working movements of the body
with normal excursion, strength, speed, coordination and
endurance. Functional loss may be due to absence of part or
all of the necessary bones, joints and muscles or associated
structures, or to deformity, adhesions, defective
innervation, or other pathology, or it may be due to pain
supported by adequate pathology. 38 C.F.R. § 4.40.
As regards to the joints, factors of disability reside in
reductions of their normal excursions of movement in
different planes. Inquiry will be directed to consideration
of less or more movement than normal, weakened movement,
excess fatigability, incoordination, impaired ability to
execute skilled movement smoothly, pain on movement,
swelling, deformity or atrophy of disuse, instability of
station, disturbance of locomotion, interference with
sitting, standing, and weight bearing. For the purpose of
rating disability from arthritis, the knee is considered a
major joint. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8
Vet. App. 202 (1995).
The General Counsel for VA issued a precedent opinion in July
1997 which held that a claimant who had arthritis and
instability of the knee could be rated separately under
Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97. When a
knee disorder is already rated under Diagnostic Code 5257
(for instability), a veteran must also have limitation of
motion which at least meets the criteria for a zero percent
rating under Diagnostic Codes 5260 (flexion limited at 60
degrees or less) or 5261 (extension limited to 5 degrees or
more) to obtain a separate rating for arthritis, if arthritis
is clinically demonstrated. In August 1998, VA General
Counsel issued VAOPGCPREC 9-98. In this opinion, General
Counsel, citing Lichtenfels v. Derwinski, 1 Vet. App. 484,
488 (1991), held that even if a claimant technically had full
range of motion but such motion was inhibited by pain, a
compensable rating for arthritis under Diagnostic Code 5003
and 38 C.F.R. § 4.59 would be available, assuming of course
that arthritis was demonstrated.
Degenerative arthritis, established by X-ray findings, will
be rated on the basis of limitation of motion under the
appropriate diagnostic codes for the specific joint or joints
involved. However, when limitation of motion of the specific
joint involved is noncompensable under the appropriate
diagnostic codes, a rating of 10 percent is applicable for
each major joint affected by limitation of motion, to be
combined, not added under Diagnostic Code 5003. 38 C.F.R.
§§ 4.59, 4.71a, Diagnostic Code 5003.
38 C.F.R. § 4.71, Plate II, indicates that normal range of
motion for the knee in a sitting position is from zero
degrees' extension to 140 degrees' flexion.
38 C.F.R. § 4.71a, Diagnostic Code 5269 provides that
limitation of leg flexion to 60 degrees warrants a
noncompensable evaluation, flexion limited to 45 degrees
warrants a 10 percent evaluation, flexion limited to 30
degrees warrants a 20 percent evaluation, and flexion limited
to 15 degrees warrants a 30 percent evaluation.
38 C.F.R. § 4.71a, Diagnostic Code 5261 provides that
limitation of leg extension to 5 degrees warrants a
noncompensable evaluation, extension limited to 10 degrees
warrants a 10 percent evaluation, extension limited to 15
degrees warrants a 20 percent evaluation, and extension
limited to 20 degrees warrants a 30 percent evaluation.
Removal of semilunar cartilage causing the knee to be
symptomatic warrants a 10 percent evaluation. 38 C.F.R.
§ 4.71a, Diagnostic Code 5259.
Impairment of a knee resulting in slight subluxation or
lateral instability warrants a 10 percent evaluation.
Moderate impairment is rated 20 percent, and severe
subluxation or lateral instability warrants a 30 percent
evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5257.
With respect to the lumbar spine, a 40 percent evaluation is
the maximum rating allowed for severe lumbosacral strain with
listing of the whole spine to the opposite side, positive
Goldthwaite's sign, marked limitation of motion of forward
bending in the standing position, loss of lateral motion with
osteo-arthritic changes, or narrowing or irregularity of
joint space, or some of the above with abnormal mobility on
forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295.
The maximum rating allowed for severe limitation of motion of
the lumbar spine is 40 percent. 38 C.F.R. § 4.71a,
Diagnostic Code 5292.
Duodenal ulcer with recurring episodes of severe symptoms two
or three times a year averaging 10 days in duration, or with
continuous moderate symptoms warrants a 20 percent
evaluation. Moderately severe symptoms from duodenal ulcer
which are less than severe but with impairment of health
manifested by anemia and weight loss, or recurrent
incapacitating episodes averaging 10 days or more in duration
at least four or more times per year warrants a 40 percent
evaluation. Severe symptoms with pain only partially
relieved by standard ulcer therapy, periodic vomiting,
recurrent hematemesis or melena, with manifestations of
anemia and weight loss productive of definite impairment of
health warrants a 60 percent evaluation. 38 C.F.R. § 4.114,
Diagnostic Code 7305.
Lumbosacral Strain: Shortly after service, service
connection was granted for chronic lumbar myositis based upon
a finding, substantiated by service medical records, that the
veteran had a preexisting low back disability that was
aggravated (increased beyond ordinary progress) during
service. That initial rating action provided a 10 percent
evaluation. VA X-ray studies of the lumbar spine in November
1951 were interpreted as being normal. The veteran's low
back disorder was later characterized as lumbosacral strain
with pain on motion. In October 1973, the RO issued a rating
action, which increased the veteran's evaluation from 10 to
20 percent effective from June 1973. That 20 percent
evaluation remained in effect until the time of this appeal.
Private outpatient treatment records from May 1974 noted
minimal tenderness of the lumbosacral area with no swelling,
and straight leg raising was essentially negative. X-ray
studies were interpreted as being negative.
In January 1983, the veteran was involved in a motor vehicle
accident with cervical spine injury and complaints of pain
throughout the back. Private medical records reveal that the
veteran injured his low back, years after service in August
1983, while lifting a desk.
A May 1996 VA orthopedic examination noted lumbosacral strain
with some limitation of motion but no radiculopathy. There
was 40 degrees' forward flexion, 15 degrees' extension, 30
degrees' flexion and 30 degrees' rotation. Lumbar X-rays
were interpreted as showing a normal alignment with narrowing
of the L4 disc space and sclerotic changes across this disc
space.
In June 1999, the veteran was provided a VA orthopedic
examination. Examination revealed no evidence of spinal
list. This examination report included review of the
veteran's claims folder, which revealed a diagnosis prostate
cancer. In May 1996, the veteran was diagnosed as having
degenerative joint disease of the lumbar spine. A bone scan
of September 1997 showed questionable metastases. PSA
(prostate specific antigen) testing had been significantly
elevated for a period of years. In December 1998, metastatic
cancer in the pubis was increasing, but the veteran refused
biopsy. Current examination revealed that the veteran's gait
was not normal and getting on and off the examining table was
very difficult for him. Any form of bending or squatting was
difficult. He was unable to walk on heels and toes. Trunk
mobility was found to be essentially absent. There was pain
on moving the lumbar spine in any direction. He could only
bend eight degrees right and left. Testing revealed
sacroiliac pain but this physician specifically noted that he
did not interpret this as abnormal sacroiliac joint disease
in the context of arthritis. Instead, this physician wrote
that "it is probably due to metastatic bone disease due to
cancer of the prostate." The diagnoses included arthritis
and degenerative joint disease of the spine in association
with metastatic cancer of the prostate to pubis and possibly
other sites.
A contemporaneous VA examination for ulcers also conducted in
June 1999 contained another VA physician's opinion that the
veteran had back pain which was believed to be significantly
contributed to by metastases from prostate cancer. VA X-ray
studies were interpreted as showing degenerative joint
disease changes between L3 and L5 with narrowed discs.
However there was no evidence of acute or chronic
compressions and the alignment was unremarkable.
During a hearing at the regional office in March 2000, the
veteran indicated that he had significant back pain and
limitation of motion.
A preponderance of the evidence on file is against an
evaluation in excess of 40 percent for the veteran's
service-connected chronic lumbar sprain with pain on motion.
The veteran's service-connected low back disability is
manifested by degenerative joint disease and severe
limitation of motion with pain on motion. However, the
current 40 percent rating is the maximum evaluation allowed
under either Code 5292 (limitation of motion) or 5295
(lumbosacral strain). As service connection is not in effect
for disc disease, 38 C.F.R. § 4.71a, Code 5293 is not
applicable. (The Board parenthetically notes that the
neurological symptoms that have been reported would fall far
short of what is required for a rating in excess of 40
percent under that code but, in any event, Code 5293 is not
for application.) The medical evidence on file shows that
the veteran aggravated a low back strain during service and
that this disability resulted in mild to moderate low back
symptoms for many years after service. It is apparent that
the veteran has little motion of the lumbar spine but the
most recent significant onset of low back pain and immobility
has been clinically attributed to metastasis of nonservice-
connected prostate cancer. Even if one assumes that all of
the limitation of motion of the veteran's lumbar spine is
attributed to his service-connected disorder, it would still
not support a rating in excess of 40 percent, as there is no
medical evidence to show that the veteran has unfavorable
ankylosis of the lumbar spine. See 38 C.F.R. § 4.71a, Code
5289. It was reported upon the most recent VA compensation
examination in June 1999 that the veteran had essentially no
trunk mobility but range of motion testing did show some
motion of the lumbar spine and there is no suggestion of
ankylosis or complete immobility of the lumbar spine at an
unfavorable angle. The currently assigned 40 percent
evaluation is an appropriate evaluation for severe limitation
of motion of the lumbar spine and/or for severe lumbosacral
strain with marked limitation of motion and loss of lateral
motion with osteoarthritic changes or narrowing or
irregularity of joint space.
Without attempting to distinguish low back symptoms
attributable to service-connected low back strain from
nonservice-connected prostate cancer with probable
metastasis, the RO gave the veteran the benefit of the doubt
in granting its most recent increase from 20 to 40 percent,
the maximum schedular evaluation for lumbosacral strain
and/or for severe limitation of lumbar spine motion.
However, no higher evaluation is warranted in the absence of
complete bony fixation (ankylosis) at a unfavorable angle.
As to the veteran's complaints of low back pain upon any
motion of the low back, the effects of pain on motion do not
permit a higher rating under 38 C.F.R. §§ 4.40, 4.45, 4.59;
DeLuca v. Brown, 8 Vet. App. 202 (1995), as the veteran's 40
percent rating is the maximum rating under the limitation-of-
motion code. Johnston v. Brown, 10 Vet. App. 80 (1997).
The preponderance of the evidence is against a rating in
excess of 40 percent for the veteran's low back disability.
Thus, the benefit-of-the-doubt doctrine does not apply, and
the claim must be denied. See, generally, Gilbert v.
Derwinski; 1 Vet. App. 49 (1990).
Duodenal Ulcer: At the time of enlistment in December 1943,
the veteran was noted as 72 inches tall and 160 pounds.
Shortly after service in 1946, the veteran was granted
service connection for a marginal, chronic duodenal ulcer on
the basis of service medical records demonstrating that
preservice stomach problems were aggravated during active
military service. A noncompensable evaluation was initially
assigned at service separation, but this was increased to a
10 percent evaluation effective in May 1946, and this
evaluation remained in effect until it was increased to 20
percent during the present appeal.
A December 1951 VA examination noted the veteran was 75
inches and 160 pounds. A July 1960 VA examination noted the
veteran weighed 168 pounds. An August 1960 X-ray study
revealed minimal deformity of the duodenal bulb due to a
previous ulcer. No active ulcer was seen at that time.
A May 1994 outpatient treatment record revealed occasional
loose stools and occasional mild abdominal pain. The veteran
was 163 pounds. There was also occasional indigestion and
belching but no melena. The veteran reported taking two to
three cups of Maalox per day and it was recommended that this
be discontinued because of the loose stools.
A report of a May 1996 VA examination of the stomach contains
the veteran's continuing complaints of bloating, belching and
indigestion which was controlled by taking antacids. He had
very few bladder symptoms. He had been told that his
prostate was enlarged and hard and that he had a high blood
test for cancer of the prostate. The veteran weighed 158
pounds. The abdomen was flat and nontender without masses.
The diagnosis was history of peptic ulcer disease, chronic,
persistent symptoms which the veteran reported as about the
same or worse.
In June 1999, the veteran was provided a VA examination of
the stomach and duodenum. The history of ulcer was discussed
and it was noted that he had intermittent episodes of
symptoms ever since service separation. It was noted that
his symptoms "come and go and he gets off his diet." He has
been on some type of stomach medicine ever since 1945. At
present he was being treated symptomatically with Amphojel or
Gelusil. An X-ray study eight months earlier was interpreted
as revealing scar tissue in the duodenal ulcer scar area.
There was no obstruction of the outlet of the stomach or
duodenum but he was still symptomatic, although there was no
ulcer crater at the present time. He had fairly good kidney
function and the abdomen was flat and nontender with no
masses. The impression was history of duodenal ulcer over
many years which was still symptomatic with abdominal pain,
belching, and bloating.
A June 1999 VA orthopedic examination recorded that the
veteran was six feet three inches tall and weighed 165
pounds, and that the veteran reported that this had been his
weight for "much over 5 years."
At his March 2000 personal hearing, the veteran indicated
that he took many kinds of medication. He indicated that he
needed to maintain a careful diet to control his symptoms.
He said his stomach was "sixty percent gone."
A preponderance of the competent clinical evidence on file is
against an evaluation in excess of 20 percent for the
veteran's residuals of a duodenal ulcer. A careful review of
the entire claims folder leads the Board to conclude the
presently assigned 20 percent evaluation for moderate overall
symptoms most nearly approximates the veteran's degree of
disability from this disorder. The relevant medical evidence
does not reveal recurring episodes of severe symptoms
occurring two or three times a year averaging 10 days in
duration, which is also a criteria for the currently assigned
20 percent evaluation. There is no evidence on file
indicative of moderately severe symptoms or recurrent
incapacitating episodes averaging 10 days or more at least
four or more times a year. Ten-day periods of exacerbated
symptoms from duodenal ulcer are not demonstrated by any
clinical evidence of record. Additionally, while the veteran
is shown most recently to be 6 feet, 3 inches tall and only
weigh 165 pounds, this is not an inconsistent weight for the
veteran historically. The Board also notes that the veteran
has prostate cancer with apparent metastasis. In any event,
he is not shown to have chronic or recurrent anemia and/or
weight loss. Accordingly, an evaluation in excess of
20 percent is not warranted.
As the preponderance of the evidence is against a rating in
excess of 20 percent for the veteran's duodenal ulcer
disease, the benefit-of-the-doubt doctrine does not apply,
and the claim must be denied. Gilbert, supra.
Left Knee: Also shortly after service, the RO granted
service connection for left knee arthralgia, rated as mild
arthritis, which was considered also to have been incurred by
aggravation during service of a preservice injury. A
10 percent evaluation was assigned in 1946 and has remained
in effect through present.
A May 1996 VA orthopedic examination revealed that the
veteran wore a soft brace on the left knee. Range of motion
was from zero to 130 degrees and the knee joint was freely
moveable. An X-ray study of the left knee was interpreted as
being "within normal limits." The diagnosis was left knee
impairment with some limitation of motion.
A June 1999 VA orthopedic examination noted that the veteran
walked with an abnormal gait favoring one leg and then the
other, but mostly favoring the right leg. Both patellas were
freely moveable with no pain but both knees did have palpable
rough surfaces. This was more prominent on the right than
the left. Extension of the left knee was full and complete
but flexion was limited to 90 degrees. There was no evidence
of ligament laxity in either knee. An X-ray study of the
knee revealed that both medial compartments were slightly
narrowed but there were no other acute bony changes and no
effusions. The impression was degenerative joint disease in
both knees.
During his March 2000 RO hearing, the veteran indicated that
he had problems with both knees and that he wore braces on
both knees. The veteran's friend testified that the veteran
had fallen down on occasion.
The presently assigned 10 percent evaluation is warranted
with arthritis and some limitation of motion in accordance
with 38 C.F.R. § 4.59 which warrants award of at least the
minimum compensable rating for the joint affected by such
arthritis. See also 38 C.F.R. § 4.71a, Diagnostic Code 5003;
DeLuca, supra; VAOPGCPREC 9-98. There is no limitation of
extension apparent and the degree of limitation of flexion
that has been shown falls far short of what is required for a
rating in excess of 10 percent. See 38 C.F.R. § 4.71, Codes
5260, 5261. As to the veteran's complaints of left knee pain
upon motion, there is no objective evidence to support a
finding that pain, flare-ups of pain, fatigue, weakness,
incoordination, or any other symptom results in additional
limitation of motion to a degree that would support a rating
in excess of 10 percent under the limitation of motion codes.
38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App.
202 (1995),
This does not end the Board's inquiry as the question remains
whether the veteran's left knee disability is manifested by
any additional impairment, to include instability or
subluxation. VA General Counsel Opinions provide that, under
certain circumstances, arthritis and instability of a knee
may be rated separately under Codes 5003/5010 and 5257.
VAOPGCPREC 9-98, 23-97. Here, there is no objective medical
evidence of instability or subluxation of the left knee. It
was specifically reported upon the most recent VA
compensation examination
In June 1999 that there was no instability or ligamentous
laxity of the left knee. However, the veteran has testified
during this appeal that he has fallen on numerous occasions
and must wear a knee brace for stability. The Board finds
that this testimony raises a reasonable doubt as to whether
his left knee disability is manifested by mild instability.
Under these circumstances, the Board finds that an increased
rating to 20 percent is warranted. 38 C.F.R. §§ 3.102,
4.71a, Code 5257; VAOPGCPREC 9-98, 23-97. There is no
medical or other competent evidence to support a finding of
more than mild instability or subluxation of the left knee.
Other Matter: During the pendency of this appeal, the
Veterans Claims Assistance Act (VCAA) of 2000 was passed into
law. This law eliminated the concept of well-grounded claims
and redefined the obligations of VA with respect to the duty
to assist. The VCAA is applicable to all claims filed before
the date of enactment and not yet final as of that date,
including all issues in this pending appeal. The VCAA
requires VA to make reasonable efforts to assist a claimant
in obtaining evidence necessary to substantiate the
claimant's claims and requires VA to notify claimants and
representatives of the evidence necessary to substantiate
those claims.
It is clear that the RO fulfilled its duty to assist as
required in the newly adopted VCAA during the pendency of
this appeal. The veteran and his representative have clearly
been informed of the evidence necessary to substantiate his
claims in the statements of the case on file. The veteran
was provided VA orthopedic and ulcer examinations consistent
with his claims for increased evaluations and all known
available medical records relevant to those claims were
collected for review. There remains no other relevant
evidence identified by the veteran which has not been
collected for review by VA. Under the circumstances, the
Board cannot find any basis upon which to remand all or any
of the appellate issues in this case for any additional
development in compliance with VCAA.
Finally, on the question of whether an extraschedular rating
is warranted for any of the disabilities at issue, the Board
does not have the authority to assign such a rating in the
first instance, nor does this case present an exceptional or
unusual disability picture which would warrant referral to
appropriate VA officials for consideration of an
extraschedular rating under 38 C.F.R. § 3.321(b)(1). Bagwell
v. Brown, 9 Vet. App. 337 (1996). In this regard, the Board
notes there is no evidence of record that the veteran's low
back, peptic ulcer disease, or left knee disability has
caused marked interference with employment (i.e., beyond that
already contemplated in the assigned schedular evaluation),
has necessitated recent frequent periods of hospitalization,
or is attended by other such factors as would render
impracticable the application of the regular schedular rating
standards.
ORDER
An evaluation in excess of 40 percent for lumbosacral strain
is denied.
An evaluation in excess of 20 percent for duodenal ulcer is
denied.
A 20 percent rating for a left knee disability is granted,
subject to the rules and regulations governing the payment of
VA monetary benefits.
R. F. WILLIAMS
Member, Board of Veterans' Appeals